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Internship Uncertainty – It’s time for a national application process

16 Aug 2017

BY DOUG ROCHE, VICE PRESIDENT (EXTERNAL) AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION

Right now, final year medical students are receiving offers of internship from hospitals around the country. For each student, this follows a long process from considering which hospitals to preference, to preparing applications, and finally submitting them. However, with a shortage of internship positions, it’s uncertain as to whether many students, particularly international students, will even get to the point of receiving an offer.

Final year students who miss out on an offer in the initial round are put in an extremely difficult position. Many of these are full-fee-paying domestic or international students, and have invested $300,000 and a substantial portion of their life to get to this point, at which inadequate foresight in workforce planning has led to the prospect of never becoming a fully qualified doctor.

The shortage of positions means that students are advised to apply to multiple States and Territories (jurisdictions) to maximise their chances of obtaining an offer. For this year’s intake, almost 1200 students applied to multiple jurisdictions.

Such duplication incurs a number of costs, not just the direct cost to the jurisdiction. The principle cost is one of time and effort for the applicant. Internship applications occur during a busy year of clinical placements when most candidates are sitting final exams. They’re also trying to balance the extracurricular commitments needed to remain competitive for specialty training program selection, on top of maintaining healthy connections with friends and family.

For those who wait many months to receive an offer, the system is hampered by multiple offers being made to the same individual, increasing the time and level of uncertainty involved. The complexity is further increased by the different application systems implemented by each jurisdiction.

For domestic graduates, all States except Victoria offer a ballot-based system. The Victorian system, merit-based but termed ‘employer choice’, requires candidates to apply to individual hospital and health services.

There are broader harms to a merit-based internship process too. Metropolitan hospitals pride themselves on being able to select the “creme de la crème” of graduates. This results in a system where gaining employment at a top Melbourne hospital is a sign of success in and of itself, thus attracting high-achieving graduates who may not necessarily have only been attracted to metropolitan practice in the first place.

At the same time, outer metropolitan, regional and rural hospitals are filled with the remainder of students, many of whom, due to the preferencing system, are international students. Rural health becomes unnecessarily stigmatised as the option of last resort.

Given the importance of filling all available positions in a timely fashion, a national audit is conducted five times throughout the year. This involves each jurisdiction submitting their data on applications and offers. These data are then compared and candidates who are holding multiple offers are identified and asked to select one offer.

The situation for international students is unconscionable. International students are not guaranteed an internship, and job prospects are the major cause of stress in most international students’ lives. The transparency with which universities advise prospective international medical students of this fact varies considerably between institutions.

AMSA surveys show that 83 per cent of international students want to stay and work in Australia, and 85 per cent of these students are interested in working in regional and rural Australia. They are well acculturated to the Australian health care system. A national process would likely accelerate offers for international students and relieve some of the uncertainty associated with becoming fully qualified.

The solution to these problems is neither complex nor particularly costly. A national internship application process would involve one portal through which students apply, receive, accept and reject offers. AMSA has been calling for such a system since 2012.

For students, a streamlined national process would relieve a great amount of the pressure of becoming a fully qualified doctor. While ideally priority systems and methods of application would be aligned, this isn’t a necessary prerequisite for a national system. A computer algorithm would be able to take into account the differences between State and Territory preferencing system. The number of final year students racing against the clock to find an internship before the end of the year would be drastically reduced.

The benefits of a national process are not only to the individual student, but to jurisdictions as well. Administrative burdens of conducting a different scheme in each State and Territory would be minimised, and a national audit would no longer be necessary as multiple offers would be impossible. Hundreds of hours of work by departmental staff would be saved.

One of the great difficulties we face is that it’s impossible to track students as they flow through the fragmented system. Universities, AMSA and jurisdictions rely on reports of individual students and the somewhat delayed results of the national audit. We have no way of knowing how many graduating doctors fall through the cracks, and are forced to either take up an internship overseas or forfeit medicine as a career.

Australia is far behind in the implementation of a centralised process for internship applications - similar systems already exist in the US, UK, New Zealand and Canada. The US, UK and Canada have vastly more complex jurisdictional arrangements than Australia, and yet their ‘match’ systems are well-established.

It’s time for State, Territory and Commonwealth health ministers and departments to show some leadership in this area. The medical workforce challenges Australia faces are only going to compound. A National Internship Application Process would be a relatively simple step to addressing these, while creating a more certain future for the students on whom Australia’s future health relies.